1. Atypical Presentation of Illness in Elders
Mary J. Dyck, PhD, RN, LNHA
Professor

2. Objectives
Identify the clinically relevant signs and symptoms of an atypical presentation of illness in an older adult.
Describe the impact of comorbidities, functional changes, and potential threats to autonomy/independence with atypical presentation.

3. Introduction
Nursing care of older adults in any practice setting requires a recognition that illness may present atypically.
Assessment is key to recognizing an atypical presentation.
Early recognition can improve plans of care, reduce risk for fatality and/or prolonged hospitalization, and reduce rates of comorbidity from treatable geriatric syndromes.
(Gray-Miceli, Dowling-Castronovo, & Bradway, 2008)

4. How do you know it is an atypical presentation?

5. Background: What Constitutes an Atypical Presentation?
Atypical presentation of illness includes:
Vague presentation of illness
Refusal or failure to eat or drink
New onset of falling
Altered presentation of illness
Absence of pain with conditions/diseases known to produce pain
Non-presentation of illness
Severe infection with a fever
(Gray-Miceli, Aselage, & Mezey, 2010; Gray-Miceli, Dowling-Castronovo, & Bradway, 2008)

6. Case Report Behavior Change Example
A 73 y.o. man with dementia and difficult behaviors, including anxiety and agitation. The behaviors were attributed to the dementia.
When treated with medications for this “behavioral” problem, it was revealed that the agitation was associated with physiological blood pressure change and surges of catecholamine. He was later diagnosed with pheochromocytoma.
(Gray-Miceli, Dowling-Castronovo, & Bradway, 2008)
Behavior Change Example

7. Case Report Mental Status Change Example
A conservative older woman in a nursing home stopped her wheelchair beside me. She started asking questions about my sex life.
We obtained a urine specimen, which was leukocyte and nitrate positive on dipstick. Antibiotics were started that day. Within a few days she was alert and oriented and NOT asking inappropriate questions.
Case Report
Mental Status Change Example

8. Importance of Recognition
Essential consideration when caring for older adults
Greatest risk of atypical presentation
Older adults over age 85 years
Multiple comorbidities and medications
Cognitive of functional impairments
(Gray-Miceli, Dowling-Castronovo, & Bradway, 2008)

9. Consequences of Not Recognizing
Lack of treatment for potentially modifiable diseases and/or geriatric syndromes
Increased morbidity
Increased mortality
Affects quality of care for all older adults in all settings
(Gray-Miceli, Dowling-Castronovo, & Bradway, 2008)

10. Assessing for Atypical Presentations
More frequent vital signs
Daily intake and output
Daily weights
Assessing pain, function, behavior, and mental status
(Gray-Miceli, Dowling-Castronovo, & Bradway, 2008)

11. Classic Signs and Symptoms Associated with Atypical Presentation
Delirium
Falls
Dehydration
Decrease in appetite or failure to eat or drink
Pain or lack of pain
Change in functional status
Change in mobility
Dizziness
Urinary incontinence
Weakness or fatigue
(Amella, 2006; Gray-Miceli, Dowling-Castronovo, & Bradway, 2008)

12. Delirium Infection Pain Dehydration Hypoxia Metabolic disturbances
Untreated anemia
Nutritional deficiencies
Drug toxicity
Psychological trauma
(Amella, 2006)

13. Falls Investigate circumstances related to a fall Possible problems
Environmental
Health-related
Possible problems
Cardiac
Musculoskeletal
Neurologic
Change in mental status
Sensory
Functional
Continence
Psychological
(Amella, 2006)

14. Dehydration Common in elders Common causes Decreased muscle mass
Blunted thirst response
Common causes
Vomiting
Diarrhea
Fever
(Amella, 2006)

15. Change in Functional Status
Significant
Active people
Extremely limited mobility
Possible causes
Anemia
Thyroid disease
Infection
Cardiovascular or respiratory insufficiency
Standardized assessment tools
Rehab referral
(Amella, 2006)

16. Dizziness Common complaint with aging Illnesses Anemia Arrhythmia
Depression
Infection
Ear disease MI
Eye problems
Stroke
Cerumen impaction
Drug toxicity
(Amella, 2006)

17. Incontinence Possible reversible causes Rehabilitation UTI
Limited mobility
Metabolic problems
Rehabilitation
(Amella, 2006)

18. Atypical Presentations of Diseases
Infection
Alterations in GI Status
Cardiac Disease

19. Infection Infection rates rise Increased mortality rates
Lower core body temperatures
Slowed inflammatory responses
(Amella, 2006)

20. Types of Infections Pneumonia UTIs Skin infections – missed
Increased respiratory rate
Decreased appetite
Decreased functioning
UTIs
Incontinence
Increased confusion and/or delirium
Falls
Skin infections – missed
(Amella, 2006)

21. Alterations in GI Status
GI bleeding
Dehydration
Crampy abdominal pain
GI obstruction
Cramps
Stringy stool or diarrhea
Vague complaints of being unwell
Diverticulosis
Diffuse pain
Low-grade fever
Appendicitis – misdiagnosed as bowel obstruction
(Amella, 2006; Martinez & Mattu, 2006)

22. Cardiac Disease MI Heart failure Symptoms EKG Often no EKG evidence
Sudden onset of dyspnea
Anxiety
Confusion
EKG
Often no EKG evidence
Heart failure
Decreased appetite
Weight gain of 2 – 3 pounds
Complaints of poor sleep
(Amella, 2006)

23. Conclusions Assessment is critical! Decreased complications
Decreased health risks
Unnecessary use of emergency rooms
Early detection
Prompt management
(Amella, 2006; Flaherty, 2010)

24. References
Amella, E. J. (2006). Presentation of illness in older adults. AORN Journal, 83(2),
Flaherty, E. (2010). Want to know more: Atypical presentation. Hartford Institute for Geriatric Nursing.
Gray-Miceli, D., Aselage, M., & Mezey, M. (2010). Teaching strategies for atypical presentation of illness in older adults. Journal of Gerontological Nursing, 36(7),
Gray-Miceli, D., Dowling-Castronovo, A., & Bradway, C. (2008). Atypical presentation in older adults with complex illness: Urinary incontinence. AACN, JAHFIGN. [GNEC presentation].
Martinez, J. P., & Mattu, A. (2006). Abdominal pain in the elderly. Emergency Medicine Clinics of North America, 24,